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PubMed1987

Seating orientations and upper extremity function in children with cerebral palsy.

This study was conducted to determine the effect of body orientation on upper extremity function in children and adolescents with cerebral palsy. Thirteen children between ages 8 and 16 and diagnosed as having spastic or athetoid cerebral palsy were placed randomly in different seating orientations (30 degrees, 15 degrees, and 0 degrees of posterior inclination and 15 degrees of anterior inclination). In each seating position, the subject performed an upper extremity activity on cue. The tests were repeated in reverse sequence. Mean performance times were different at all seating orientations for both types of subjects. Performance time was lowest at the 0-degree orientation during the retest for the subjects with spasticity and highest at 15-degree anterior inclination during the retest for the subjects with athetosis. The results of this study show that orientation of the body in space affects upper extremity function and emphasizes the importance of positioning for maximizing upper extremity function.

Activities of Daily Living↗

PubMed1998

Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients.

PURPOSE: The efficacy of color flow duplex imaging (CFDI) in detecting proximal upper extremity venous outflow obstruction in hemodialysis patients was compared with that of traditional contrast venography. METHODS: From 1993 through 1997, all hemodialysis patients who were evaluated for upper extremity venous outflow obstruction of the axillary, subclavian, or brachiocephalic veins with both CFDI and venography were identified. Medical history, hemodialysis access procedures, and indications for imaging were reviewed. The diagnostic accuracy of CFDI was compared with that of venography for proximal venous outflow obstruction, including focal stricture, partial obstruction, or complete occlusion. RESULTS: Sixty upper extremities in 42 hemodialysis patients were imaged with both CFDI and venography. Previous ipsilateral intravenous dialysis catheters had been present in 33 (55%) of the extremities imaged; current catheters were present in 16 (27%) of the extremities imaged; and 28 (67%) of the extremities imaged had a current ipsilateral arteriovenous (AV) shunt. Five (8%) of the 60 duplex scans were nondiagnostic because of artifact from intravenous dialysis catheters (3) or incomplete visualization of the subclavian or brachiocephalic veins (2) and were excluded from further analysis. In the remaining 55 duplex scans, proximal venous outflow obstruction was found in 18 (33%), compared with 21 (38%) identified by means of venography (P = not significant [NS]). Overall sensitivity, specificity, positive predictive value, and negative predictive value for CFDI were 81%, 97%, 94%, and 89%, respectively. CONCLUSION: CFDI is a reliable means of detecting proximal upper extremity venous outflow obstruction and should replace contrast venography as the initial imaging study in hemodialysis patients.

Adult↗

PubMed1987

Evaluation of impairment in the upper extremity.

A system for evaluation of physical impairment in the hand and upper extremity was developed and has been tested and used by many hand surgeons around the world. It was approved for international application by the International Federation of Societies for Surgery of the Hand. A method for evaluating amputation and sensory and motion impairments has been devised for the hand and upper extremity. Amputation impairment percentage values were determined for each digit or position thereof for the hand, wrist, elbow, and shoulder. By a principle of progressive multiplication of percentage values, impairment of a part can be related to the hand, upper extremity, and eventually the whole person. Sensory impairment is given 50% that of an amputation. Impairment of finger motion can result from lack of flexion (F), extension (E), or ankylosis (A). The method for evaluating flexion impairment is based on a combined angular measurement principle that was correlated with the linear measurement of Boyes. Values for flexion and ankylosis impairment were obtained from the American Medical Association guide. Values for extension impairment were derived from the formula A = E + F. Values for hyperextension were given consideration in the impairment tables. The sum of impairments as related to the whole hand equals the total impairment. The method to combine various impairments is based on the principle that each impairment acts not on the whole part (e.g., the finger) but on the remaining portion (e.g., proximal interphalangeal joint and proximally) after the preceding impairment has acted (e.g., on the distal interphalangeal joint). When there is more than one impairment to a given part, these must be combined before conversion to a larger part. The combined values determination is based on the formula "A% + B% (100% - A%) = the combined values of A% + B%." Based on this principle, the physical loss of each anatomic segment is related to the part, to the entire hand, and then to the body. The common impairment values have been placed in a table form for easier use.

Accidents, Occupational↗

PubMed1997

[Myelopathy due to vitamin B12 deficiency presenting only sensory disturbances in upper extremities: a case report].

We report a 54-year-old man with vitamin B12 deficiency myelopathy limited to the upper extremity region. He was well until October, 1995, when he had an onset of exertional dyspnea and general fatigue. Then he noted tingling sensation in bilateral upper extremities in March, 1996. He had undergone total gastrectomy due to gastric ulcer 15 years ago. Neurological examination revealed superficial and vibratory sensory loss in the upper extremities distal to elbows, and pseudoathetoid movement of the left fingers. Otherwise neurological examination was unremarkable. Laboratory examination revealed macrocytic anemia, and low serum vitamin B12. However, serum folate was within the normal range. In SEP studies, median nerve stimulation evoked peripheral N9 and N13 potentials, but not cortical N20 one. Posterior tibial nerve stimulation elicited normal responses. MEP, VEP, needle EMG, and nerve conduction studies gave normal findings. T2-weighted MRI showed high signal intensity lesions at the C1-Th1 level in the posterior column, especially in the cuneate fascicles. The gracile fascicles were spared. This is a very rare case of myelopathy due to vitamin B12 deficiency presenting only sensory disturbances in both upper extremities. The lesions limited in the cuneate fascicle were confirmed by electrophysiological, and neuroradiological examinations.

Arm↗

PubMed2000

An evaluation of botulinum-A toxin injections to improve upper extremity function in children with hemiplegic cerebral palsy.

OBJECTIVE: In a randomized, controlled, single-blind trial, to test the hypothesis that botulinum-A toxin (BTA) injections into the upper extremity of children with spastic hemiplegia improve upper extremity function. STUDY DESIGN: Thirty children with hemiplegia, aged 2.5 to 10 years, were randomly assigned to receive: (1) a BTA injection into 1 or more of 3 muscle groups (biceps, volar forearm muscles, adductor pollicis) plus occupational therapy or (2) occupational therapy alone. Blinded outcomes obtained at baseline and at 1, 3, and 6 months included the Quality of Upper Extremity Skills Test (QUEST), goniometry measurements, grip strength, and Ashworth scores. The caregiver completed the self-care domain of the Pediatric Evaluation of Disability Inventory. RESULTS: Twenty-nine subjects completed the study. The QUEST demonstrated a significant improvement favoring the treatment group on a 2-way analysis of variance (F = 4.69, df = 1,83; P =.039). BTA treatment was also associated with an improvement in score on the self-care domain of the Pediatric Evaluation of Disability Inventory (F = 4.68, df = 1,82; P =.04). CONCLUSIONS: This study supports the effectiveness of BTA injections to improve upper extremity function of children with hemiplegia who have at least moderate spasticity.

Analysis of Variance↗

PubMed2001

Back and upper extremity disorders among enlisted U.S. Marines: burden and individual risk factors.

Although musculoskeletal disorders of the low back and upper extremities can affect military readiness, little is known about their extent and risk factors in the U.S. Marine Corps. Using the Defense Medical Epidemiology and Defense Medical Surveillance System databases, back and upper extremity diagnostic categories were among the top four sources of outpatient visits and duty limitation among enlisted Marines. Back disorders were also found to be the fifth most common cause for lost time. Subsequently, high-risk occupations were identified, age-related trends for clinic visit rates were determined, and rate ratios were computed for the top 15 low back and upper extremity diagnoses among enlisted Marines from 1997 through 1998. Occupational categories with the highest rates of musculoskeletal-related outpatient visits included image interpretation, auditing and accounting, disturbsing, surveillance/target acquisition, and aircraft launch equipment. Significantly increasing linear trends in rates across age groups were found for most diagnoses. For 1998, age-specific rate ratios indicated significantly higher rates for most low back and upper extremity disorders for females; lower rank (i.e., E1-E4) was also a risk, but for fewer diagnoses. The findings emphasize the need to identify modifiable (e.g., work-related, individual) risk factors and to develop focused primary and secondary prevention programs for musculoskeletal disorders in the Marine Corps. Subsequently, these efforts can assist in reducing associated effects, maximizing resource utilization, and enhancing operational readiness.

Adult↗

PubMed2005

Return to play issues in upper extremity injuries.

OBJECTIVE: The purpose of this paper is to outline general treatment and return to play (RTP) strategies as they pertain to athletes with various upper extremity injuries. It is not intended to be a comprehensive review of these injuries. DATA SOURCES/SYNTHESIS: A review of the literature plus expert opinion served as the basis for recommendations made regarding management strategies for returning the athlete to play after upper extremity injury. A Medline search was performed using the following key words: upper extremity injury, return to play, glenohumeral dislocation, acromioclavicular joint sprains, elbow dislocation, scaphoid fracture, metacarpal fracture, finger dislocation, tendon injury, hand, mallet finger, and jersey finger. These and other related terms were crossed using the Medline database from 1966 to 2005. RESULTS: Review of book chapters, articles generated from the Medline search, and expert opinion led to the recommendations that are presented here. There is general agreement regarding the treatment of many of the injuries discussed, but controversies do exist. RTP guidelines are largely dependent on the severity of initial injury, rates of healing, and return of strength. CONCLUSIONS: Each athlete with a particular injury to the upper extremity needs to be approached as an individual as no single set of treatment or RTP guidelines applies to all injuries or all individuals. Factors such as age, injury severity, hand dominance, type of sport participation, method of treatment, and chronicity of injury are among the many issues that must be considered when developing a treatment and RTP strategy for a particular athlete.

Acromioclavicular Joint↗

PubMed1995

Work-related upper-extremity disorders and work disability: clinical and psychosocial presentation.

Work-related upper-extremity disorders (WRUEDs) are an increasingly common cause of work-related symptoms and disability. Although most upper-extremity disorders are acute and self-limited, a small percentage of workers with symptoms go on to permanent disability and account for the majority of costs associated with these conditions. Little is known, however, about this progression from symptoms to disability and how it might be prevented. In this study, we evaluate the demographic, vocational, medical, and psychosocial characteristics of patients with WRUEDs and examine several hypotheses regarding the differences between working and work-disabled patients. One hundred twenty-four consecutive patients were evaluated in a clinic specializing in occupational upper-extremity disorders. Patients currently working (n = 55) and work-disabled patients (n = 59) were similar with regard to age, gender, and reported job demands. The work-disabled group reported less time on the job, more surgeries, a higher frequency of acute antecedent trauma, and more commonly had "indeterminate" musculoskeletal diagnoses. They also reported higher pain levels, more anger with their employer, and a greater psychological response or reactivity to pain. These findings, though cross-sectional in nature, suggest that, in addition to medical management, more aggressive approaches to pain control, prevention of unnecessary surgery, directed efforts to improve patients' abilities to manage residual pain and distress, and attention to employer-employee conflicts may be important in preventing the development of prolonged work disability in this population.

Adult↗

PubMed1993

[Dynamic roles of the upper extremity during axillary crutch gait].

To ambulate successfully with an axillary crutch, the upper extremities play an important part in supporting the body's entire weight. To evaluate the roles of the upper extremity during axillary crutch gait 15 normal adult subjects, 23 patients with an affected single leg, and 3 patients with rheumatoid arthritis (RA), were investigated. The gait patterns using crutches were: the one-leg swing-through crutch gait and three-point crutch gait for both normal subjects and patients with an affected single leg, and the three-point crutch gait for RA patients. The real-time motion analysis system "Quick-MAG", force plates, and a VTR system were used for data acquisition. The forces at the arm-pit and the hands during the swing-through crutch gait decreased when the cadence increased from 60 to 100 steps per minute. However, the floor reaction curve suggested distortion of the rubber at the crutch tip when the cadence reached 100. In the plane of progression during the crutch stance phase, the elbow flexion angle was about 14 degrees, and the wrist radial flexion angle about 23 degrees in the middle of the crutch stance phase. This position might be the best for efficient force exertion from the upper extremity. The unloading ratio during the three-point crutch gait was 35 percent in the normal subjects, 49 percent in patients with an affected single leg, and 14 percent in the RA patients. The results of the unloading ratio, indicated that elbow and wrist joint impairment prevented the RA patients from sustaining enough posture to support body weight during the three-point crutch gait.

Adolescent↗

PubMed1980

Chronic vascular disease of the upper extremity: radiologic and clinical features.

The major chronic vascular diseases of the upper extremity are (1) subclavian artery occlusions, (2) thoracic outlet syndrome, and (3) angiospastic disease of the hand. Central subclavian artery lesions ease of the hand. Central subclavian artery lesions can have either hemodynamic consequences (subclavian steal syndrome) or, by peripheral embolization, can provoke ischemic symptoms of the hand. Costoclavicular narrowing can cause functional or fixed stenosis of the subclavian artery and can also involve the vein or brachial plexus. Symptoms due to pressure on the brachial plexus are most frequent, but embolization to the peripheral vessels may also occur. Angiospastic disease, the most frequent lesion of upper extremity vessels, comprises three types: Raynaud's disease, in which there are intermittent attacks of coldness and discoloration without evidence of occlusion on the angiogram; asphyxia manus et digitorum in which the attacks are also intermittent but there is morphologic evidence of occlusion; and digitus moriens or mortuus, in which there is a painful, permanent discoloration. All investigations of chronic vascular disease of the upper extremity should begin with arch aortography and then proceed to a selective catheterization of the vessels that are presumed to be involved.

Adolescent↗

PubMed2004

Upper extremity deep venous thrombosis: interventional management.

Upper extremity deep venous thrombosis, previously thought to be a relatively innocuous disorder in comparison to lower extremity deep venous thrombosis, has recently begun to receive the attention it merits. Its optimal management remains controversial despite the development of several new techniques and devices which allow more rapid removal of thrombus and treatment of underlying venous stenotic disease. The following article provides a framework to discuss its treatment, with the emphasis on endovascular management.

Disease Management↗

PubMed1987

Results of fractional lengthening of the finger flexors in adults with upper extremity spasticity.

Flexor spasticity is common in the upper extremity after insult to the central nervous system. This leads to decreased function and hygiene problems as a result of the inability to extend the fingers. The results of fractional lengthening of the finger flexors of 27 patients with upper extremity flexor spasticity of the finger flexors were examined. Patients were divided preoperatively into those with potentially functional hands and those who were nonfunctional based on the presence of motor control and hand sensibility. Follow-up time averaged 33 months. Postoperatively, all five nonfunctional hands, which lacked any motor control, improved in posture, and the hygiene problems resolved. Twenty of the 22 patients with potentially functional hands (91%) improved their spastic hand function score, a mean of 3.7 points. Two patients (9%) decreased their spastic hand function score as a result of overlengthening of the finger flexors, with loss of grip strength.

Adult↗

PubMed2005

Choice-based evaluation for the improvement of upper-extremity function compared with other impairments in tetraplegia.

OBJECTIVES: To assess preference of reconstructive treatment of upper extremities in subjects with tetraplegia compared with preference of treatment of 3 other impairments and to determine the effect of subjects' characteristics on preference of upper-extremity reconstruction. DESIGN: Survey. SETTING: Two specialized spinal cord injury centers in the Netherlands. PARTICIPANTS: A consecutive sample of 47 patients with tetraplegia in stable condition. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The quality weight of 5 tetraplegic health states determined with the time trade-off technique and expressed as a single value (the "utility") on a scale between 0 (worst possible situation) and 1 (best possible situation). RESULTS: The response rate was 92%. The utility of tetraplegia +/- standard deviation was .57+/-.30. The utilities of tetraplegia without impairment in one of the following functions were .69+/-.33 for sexuality, .69+/-.33 for standing/walking, .63+/-.31 for bladder and bowel function, and .65+/-.32 for upper-extremity function. The differences between these utilities and the utility of tetraplegia were significant (P<.05). No significant differences were found between the utilities of the impairments. Improvement of a specific impairment contributed between 14% and 28% to the potential overall gain in the tetraplegic health state utility. CONCLUSIONS: The combination of impairments determines the low utility of the tetraplegic health state. No priority for improvement of any of the investigated impairments was found. This emphasizes the need for the meticulous selection of patients for treatment of specific conditions. Further research should try to determine the crucial factors in the decision-making process of patients for specific interventions.

Adult↗

PubMedDate not supplied

Upper extremity wringer injury.

A clinical survey of 92 upper extremity wringer injuries over the past four years at the Bexar County Hospital are presented. Our treatment regimen and results are outlined. Complex injuries occurred infrequently (7%). No vascular insufficiency developed and no fasciotomies were required. We are of the opinion that hospitalization is necessary in all but a small number of selected cases. Close observation is necessary to prevent edema progression and further tissue loss. Ninety-two upper extremity compression injuries secondary to washing machine wringers were reviewed. Seventy-six percent of the injuries occurred in persons under 10 years of age. Extremity distribution was equal. Injury occurred below the elbow in 72% of the extremities. Soft tissue injury was manifested by swelling and tenderness in 96%. Twenty-one percent had no violation of the skin. Major avulsion, such as third degree skin loss, crush injury, dislocation, and tendon avulsion, occurred in 8%. The treatment regimen consisted of surgical preparation with Betadine, compressing dressing, and elevation. Observation of the involved extremity is made every hour for development of vascular insufficiency. Fractures and other major injuries were treated as indicated. No fasciotomy was required. No vascular insufficiency developed. SKin slough was present in 16 of 92 extremities and skin graft was required in 5 of the 16. Results of treatment reveal 87% with no functional impairment of the involved extremity. Varying degrees of impairment are present in 6% of the injured extremities with all localized to the major avulsion group of injuries.

Accidents, Home↗

PubMed2004

Diagnosis and management of deep vein thrombosis of the upper extremity: a review.

Deep vein thrombosis of the upper extremity is an increasing clinical problem due to the use of long-term indwelling catheters for chemotherapy or long-term feeding. The clinical diagnosis is difficult to make, and various imaging modalities have been used for this purpose. The use of (interventional) radiological procedures has been advancing in recent years. This review describes the clinical background, the imaging modalities that may be employed, treatment options and outcome of patients with upper extremity thrombosis.

Anticoagulants↗

PubMed1985

Venous gangrene of the upper extremity.

Gangrene of the hand associated with acute upper extremity venous insufficiency has been seen in four limbs in three patients treated at Vanderbilt University Medical Center. All three patients had life-threatening illnesses associated with diminished tissue perfusion, hypercoagulability, and venous injury. One patient progressed to above-elbow amputation, but venous thrombectomy in one limb and thrombolytic therapy in two others were successful in preventing major tissue loss. All three patients eventually died from their underlying illness. Thirteen previously reported patients with "venous gangrene" of the upper extremity have been analyzed. An underlying life-threatening illness was present in the majority of these patients (7/13, 54%) and, like the Vanderbilt series, amputations were frequent (7/13, 54%) and mortality (5/13, 38%) was high. This unusual form of ischemia appears to be produced by permutations of global circulatory stasis, subclavian or axillary vein occlusion, and peripheral venous thrombosis. Early, aggressive restoration of adequate cardiac output and thrombectomy and/or thrombolytic therapy may provide the best chance for tissue salvage and survival in this group of patients.

Adolescent↗

PubMed2000

Focal upper extremity neuropathy in neonates.

Focal upper extremity neuropathies are common in neonates. The brachial plexus is the most common site involved. Brachial plexus injuries may involve different structures, thus producing different clinical presentations: complete brachial plexus palsy, Duchenne-Erb palsy, upper-middle trunk brachial plexus palsy, Klumpke palsy, fascicular brachial plexus palsy, and bilateral brachial plexus palsy. The causes of brachial plexus palsy are obstetric injury, intrauterine compression, humeral osteomyelitis, hemangioma, exostosis of the first rib, neck compression, and neoplasm. The differential diagnosis of brachial plexus palsy includes pseudoparesis, amyoplasia congenita, congenita varicella syndrome, and neurological lesions at other neuroanatomical levels. The cause and the degree of injury dictate the prognosis. The prognosis of obstetric brachial plexus injury is usually good.

Arm Injuries↗

PubMed1977

Current status of total joint replacement in the upper extremity.

The principles ot total joint arthroplasty recently have been expanded to the upper extremity, following the dramatic success with total hip and total knee replacement procedures. New problems have been encountered with the rebalancing of the soft tissues and the technical nature of joint mechanics in the upper extremities. Work on shoulder joint replacement is in the very early stages and of unknown success. Several prostheses are being used and tested. For elbow and wrist replacement, early and predictable success has been accomplished, enabling relief of pain and satisfactory motion. Total joint replacement in the fingers and thumb has provided excellent relief of pain but has been hindered by difficulties in rebalancing the soft tissues in patients with rheumatoid arthritis. It appears that total reconstruction of arthritic upper-extremity joints will be commonplace in the not-too-distant future. Clinical trials are being expanded, with increasing success.

Aged↗